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The Phyllis E. Edwards
Nursing Scholarship Award
TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES
Completeness and neatness ensure your application will be reviewed properly. Application postmark deadline April 30
I.D. #
AA
PD
RIC/CS
GPA
SATCR
SATM
SATW
ACTC
TOTAL
Last Name First Middle Initial
Permanent Home
Mailing Address Apartment #
City State ZIP Code
Telephone ( ) Date of Birth: Month Day Year
Email Address (Required for notification)
Please indicate your status. (For statistical purposes only) Male Female
American Indian/Alaska Native Black/African American Multi-Racial White
Asian Hispanic/Latino Native Hawaiian/Pacific Islander
Last Name First Middle Initial
Address
Relationship to Applicant Day Telephone ( )
Email Address
School Name High School Graduation Date: Month Year
City State Telephone ( )
Please list the eligible Michigan College you have been accepted to and plan to attend.
City: State: MI
This is a 4 yr. College or University 2 yr. Community or Junior College
Year in school next year: 1 2 3 4 5
Major or course of study: Expected college graduation date: Month Year
Degree sought: BSN ADN Other, explain
BHNURSE PDF 2/17
Copyright
©
2017 Scholarship America All Rights Reserved
APPLICANT
DATA
HIGH
SCHOOL
DATA
POST-
SECONDARY
SCHOOL
DATA
FOR
SCHOLARSHIP
AMERICA
USE ONLY
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Sending a resumé does not replace any part of this application. If space provided in any section is inadequate, you may continue on additional sheets.
Attachments must follow the same format. DO NOT repeat information already reported on the application form. Your name, address and name of this
scholarship program should be included on all attachments.
Describe your work experience during the past four years (e.g., food server, babysitting, lawn mowing, office work). Indicate dates of
employment for each job and approximate number of hours worked each week.
Employer/Position
From - Mo/Yr
To - Mo/Yr
Hours per Week
Were you paid for
your work?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
List all school activities in which you have participated during the past four years (e.g., student government, music, sports, etc.). List all
community activities in which you have participated without pay during the past four years (e.g., Boy/Girl Scouts, hospital volunteer, Special
Olympics). Note all special awards, honors and offices held. Indicate whether high school or college activities.
Activity
No. of
Years
Partic.
Special Awards,
Honors
Offices Held
Activity
No. of
Years
Partic.
Special Awards,
Honors
Offices Held
Make a brief statement or summary of your plans as they relate to your educational and career objectives and long-term goals.
Please describe how and when any unusual family or personal circumstances have affected your achievement in school, work
experience, or your participation in school and community activities.
BHNURSE PDF 2/17 Copyright
©
2017 Scholarship America All Rights Reserved
UNUSUAL
CIRCUMSTANCES
WORK
EXPERIENCE
ACTIVITIES,
AWARDS AND
HONORS
GOALS
AND
ASPIRATIONS
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To the Applicant: This section is required and must be completed in the format provided. If incomplete, your application will not be
evaluated. The section is to be completed by a high school or college counselor or advisor, an instructor, or a work supervisor who knows
you well.
To the Adult Appraiser: You have been asked to provide information in support of this application. Please give immediate and serious
attention to the following statements. When complete, please return to applicant. If you prefer, photocopy this section and return to applicant
in a sealed envelope. A letter of recommendation does not replace this section.
The applicant’s choice of a postsecondary educational
program is
extremely
appropriate
very appropriate
moderately
appropriate
inappropriate
The applicant’s achievements reflect his/her ability
extremely well
very well
moderately well
not well
The applicant’s ability to set realistic and attainable goals is
excellent
good
fair
poor
The quality of the applicant’s commitment to school and/or
community is
excellent
good
fair
poor
The applicant is able to seek, find, and use learning resources
extremely well
very well
moderately well
not well
The applicant demonstrates curiosity and initiative
extremely well
very well
moderately well
not well
The applicant demonstrates good problem-solving skills, follows
through, and completes tasks
extremely well
very well
moderately well
not well
The applicant’s respect for self and others is
excellent
good
fair
poor
Comments:
Appraiser’s Name Title Telephone ( )
Signature Organization Date
A complete transcript of grades must be sent with this application. Grade reports are not acceptable.
1. Students currently or previously enrolled in college or vocational-technical school must include all college or vo-tech transcripts of
grades from each school attended. Online transcripts must display student name, school name, grade and credit hours earned for each
course, and term in which each course was taken. (Completion of high school information below is not necessary.)
2. High school seniors and students who have completed less than one full quarter or semester of postsecondary education must
include a high school transcript of grades and have this section completed by the appropriate school official. (A clear explanation of the
high school’s grading scale must also be submitted.)
Applicant ranks _______
in a class of __________
Cumulative Grade Point Average
SAT
ACT
Weighted: __________/4.0 scale
Unweighted: ________/4.0 scale
Critical
Reading
Math
Writing
English
Math
Reading
Science
Composite
School Official’s
Signature Date Title Telephone ( )
School Official’s
Address: Street City State ZIP Code
The student is responsible for submitting all materials to Scholarship America on time. Incomplete applications will not be evaluated. This
application becomes complete and valid only when all of the following materials have been received:
Student Application with completed Applicant Appraisal
Current Complete Transcript(s) of Grades
(including grading scale)
Postmark deadline April 30
CERTIFICATION Scholarship America and the Beaumont Health selection committee has the sole responsibility for selecting recipients based on criteria as
set forth in the program’s description. This application becomes the property of Scholarship America. (It is recommended you keep a copy for
your files.)
I acknowledge decisions are final. I certify I meet eligibility requirements of the program as described in the guidelines and the
information provided is complete and accurate to the best of my knowledge. If requested, I will provide proof of information, including an
official transcript of grades. Falsification of information may result in termination of any award granted. I give Scholarship America
permission to release my application and supporting documents to Beaumont Health if I am selected as a finalist.
Applicant’s Signature Date
Parent’s Signature Date
BHNURSE PDF 2/17 Copyright
©
2017 Scholarship America All Rights Reserved
APPLICANT
APPRAISAL
(REQUIRED)
All materials, including transcript, must be addressed to:
The Phyllis E. Edwards Nursing Scholarship Award
Scholarship America
One Scholarship Way
Saint Peter, MN 56082
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